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Philipp Schuetz, Jörg D Leuppi, Roland Bingisser, Michael Bodmer, Matthias Briel, Tilman Drescher, Ursula Duerring, Christoph Henzen, Yolanda Leibbrandt, Sabrina Maier, David Miedinger, Beat Mueller, Andreas Scherr, Christian Schindler, Rolf Stoeckli, Sebastien Viatte, Christophe von Garnier, Michael Tamm, and Jonas Rutishauser

Objective

To analyze prospectively the hypothalamic–pituitary–adrenal (HPA) axis and clinical outcome in patients treated with prednisone for exacerbated chronic obstructive pulmonary disease (COPD).

Design

Prospective observational study.

Subjects and methods

Patients presenting to the emergency department were randomized to receive 40 mg prednisone daily for 5 or 14 days in a placebo-controlled manner. The HPA axis was longitudinally assessed with the 1 μg corticotropin test and a clinical hypocortisolism score at baseline, on day 6 before blinded treatment, at hospital discharge, and for up to 180 days of follow-up. Prednisone was stopped abruptly, irrespective of the test results. Patients discharged with pathological test results received instructions about emergency hydrocortisone treatment.

Results

A total of 311 patients were included in the analysis. Mean basal and stimulated serum total cortisol levels were highest on admission (496±398 and 816±413 nmol/l respectively) and lowest on day 6 (235±174 and 453±178 nmol/l respectively). Pathological stimulation tests were found in 63, 38, 9, 3, and 2% of patients on day 6, at discharge, and on days 30, 90, and 180 respectively, without significant difference between treatment groups. Clinical indicators of hypocortisolism did not correlate with stimulation test results, but cortisol levels were inversely associated with re-exacerbation risk. There were no hospitalizations or deaths as a result of adrenal crisis.

Conclusion

Dynamic changes in the HPA axis occur during and after the treatment of acute exacerbations of COPD. In hypocortisolemic patients who were provided with instructions about stress prophylaxis, the abrupt termination of prednisone appeared safe.

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Cihan Atila, Clara O Sailer, Stefano Bassetti, Sarah Tschudin-Sutter, Roland Bingisser, Martin Siegemund, Stefan Osswald, Katharina Rentsch, Marco Rüegg, Sabrina Schaerli, Gabriela M. Kuster, Raphael Twerenbold, and Mirjam Christ-Crain

Objective: The pandemic of coronavirus disease (COVID-19) has rapidly spread globally and infected millions of people. The prevalence and prognostic impact of dysnatremia in COVID-19 is inconclusive. Therefore, we investigated the prevalence and outcome of dysnatremia in COVID-19.

Design: The prospective, observational, cohort study included consecutive patients with clinical suspicion of COVID-19 triaged to a Swiss Emergency Department between March and July 2020.

Methods: Collected data included clinical, laboratory and disease severity scoring parameters on admission. COVID-19 cases were identified based on a positive nasopharyngeal swab test for SARS-CoV-2, patients with a negative swab test served as controls. The primary analysis was to assess the prognostic impact of dysnatremia on 30-day mortality using a cox proportional hazard model.

Results: 172 (17%) cases with COVID-19 and 849 (83%) controls were included. Patients with COVID-19 showed a higher prevalence of hyponatremia compared to controls (28.1% vs. 17.5%, p<0.001); while comparable for hypernatremia (2.9% vs 2.1%, p=0.34). In COVID-19 but not in controls, hyponatremia was associated with a higher 30-day mortality (HR 1.4, 95%-CI 1.10-16.62, p=0.05). In both groups, hypernatremia on admission was associated with higher 30-day mortality (COVID-19: HR 11.5, 95%-CI 5.00-26.43, p<0.001; controls: HR 5.3, 95%-CI 1.60-17.64, p=0.006). In both groups, hyponatremia and hypernatremia were significantly associated with adverse outcome, e.g. intensive care unit admission, longer hospitalization, and mechanical ventilation.

Conclusion: Our results underline the importance of dysnatremia as predictive marker in COVID-19. Treating physicians should be aware and appropriate treatment measures taken in patients with COVID-19 and dysnatremia.